Journal of the American Medical Informatics Association, 0(0), 1–3
doi: 10.1093/jamia/ocaa078
Advance Access Publication Date: 28 April 2020
Perspective
Impact of the digital divide in the age of COVID-19
Anita Ramsetty and 1Cristin Adams1
Department of Family Medicine, Medical University of South Carolina, 5 Charleston Center, Suite 263, Charleston, SC 29425
Corresponding Author: Anita Ramsetty, MD, Department of Family Medicine, Medical University of South Carolina, 5
Charleston Center, Suite 263, Charleston, SC 29425; ramsetty@musc.edu
Received 20 April 2020; Revised 22 April 2020; Editorial Decision 23 April 2020; Accepted 24 April 2020
Key words: digital divide, underserved populations, underserved care
In early 2020, talks of preparation for coronavirus disease 2019
(COVID-19) were furiously circulating around the healthcare system
nationwide, and having seen what was occurring in China, and later in
Italy, we feared what was to come. Like many others, our hospital sys-
tem began looking closely at the recommendations for decreasing
transmission of COVID-19, chief among them social distancing. By
early March, the need for an immediate adaptation of our clinical care
delivery system was clear. Within a week, clinics had transitioned from
in-person visits to telehealth involving telephone or video. Screening
processes for COVID-19 were quickly made available on a free online
platform through which at-risk individuals were directed to drive-
through centers for in-person testing.
The problem was that many of our patients could not access the
online system.
In our roles as directors of free clinics, we have become intimately
involved with the complexity inherent to the care of underserved popu-
lations, including how seemingly innovative programs can sometimes
not meet their intended goals. The CARES clinic has a main site and a
rural outreach site that treat uninsured adult patients and a pediatric
immunization clinic for uninsured and underinsured children. The 529
Meeting Street clinic treats patients at a drop-in resource center serving
individuals experiencing housing instability. Levels of literacy, extent
of chronic diseases, and complexity of social circumstances for patient
populations at both clinics are highly variable.
As our main hospital system was transitioning to telehealth-
based care, we were rapidly trying to put measures into place at our
free clinics that would ensure that our patients did not lose their ac-
cess to health care. It quickly became apparent that the newly built
telehealth systems created additional access hurdles for our free
clinic patients, and we would soon learn that pockets existed within
the larger population that were impacted by these barriers. As is of-
ten the case, those whose access was impeded were the most vulner-
able to poor health outcomes related to COVID-19.
C The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.
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Perspective
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This was not unique to our community, and in fact it was re-
peated throughout the country when other hospital systems transi-
tioned to telehealth as a sensible and efficient way to deliver health
care while implementing social distancing to combat the spread of
COVID-19. Simultaneously, the diminished accessibility to technol-
ogy based on various societal and social factors, sometimes referred
to as the digital gap or digital divide, was being exposed at a critical
time in a public health crisis. Frighteningly, there were no measures
at the ready to address it.
Use of telehealth platforms has been on the rise over the past sev-
eral years. Telehealth has been lauded as a means to close the health-
care gap to rural populations1; however, recent authors have raised
the concern that technology may actually be widening the gap be-
tween groups both nationally and even globally due to persistent so-
cial, economic, and political factors.2,3 Taken within the context of
several social determinants of health, we can see how the digital di-
vide occurs and can perpetuate inequity based on various social fac-
tors (Table 1). In fact, the American Medical Informatics
Association (AMIA) called for it to be included as a social determi-
nant of health in 2017.4
Regarding the patient populations seen in our free clinics, our
first concern was physical access to Internet services, defined largely
by built environment factors. Our homeless population lacked reli-
able Internet access outside of the technology center at the clinic.
About a third of those served at the rural CARES clinic site do not
have Internet access in their homes. This is not unlike the Federal
Communications Commission report in 2018 showing that within
the United States, 31% of rural households still lack access to broad-
band Internet.5
A combination of technology and in-person services has been
found to help address some of this disparity,3 and in our case, a di-
rect combination of the 2 types of service proved necessary. At the
529 Meeting Street clinic, a program was developed whereby staff
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Table 1. The digital divide in the context of pertinent social determinants of health

Built environment Social and community Education Economic stability Health and healthcare
context access

Contributions to the Lack of broadband Shared or cultural Literacy; varying Inability to purchase Choices of technol-
digital divide in Internet availability expectations re- degrees of digital devices or ogy/programs
health care region-wise; limited garding use of digi- literacy; inconsis- upgrades; afford- heavily tied to re-
access to free public tal devices, tent or unavailable able devices may imbursement;
Internet in commu- telehealth, and tele- education regard- not have capability healthcare systems

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nity buildings such monitoring; mis- ing changes in tech- to work with pro- likely to pursue ad-
as libraries; absence trust of technology nology posed programs; in- vanced technology
of structural sup- and/or medical consistent access to that may outpace
port/housing inse- community devices due to eco- patient capability;
curity nomic instability patient comorbid-
ities may affect
ability to effectively
use technology

would complete online screening for patients over the telephone and
in person via centrally linked accounts. At the CARES clinic, student
volunteers and providers performed this service for patients who
were able to call into the clinic. This workflow served as a template
that was replicated by our health system at large to connect individ-
uals without Internet access to the online screening tool through a
dedicated phone line staffed by volunteers. In this way, the health-
care team served as a proxy and conduit to connect patients to the
only provided method for COVID-19 prescreening, which was re-
quired to obtain a referral to the drive-through testing area.
However, the digital gap does not occur solely due to accessibil-
ity to the Internet, and the reasons for slow adoptability of tele-
health by various populations are several and sometimes
intertwined, as Table 1 shows. For instance, the CARES clinic treats
an immigrant population that has been shown to have hurdles to
adopting telemedicine6 that are not always directly linked to Inter-
net accessibility. The United States entered the COVID-19 crisis
with many factors already contributing to a healthcare divide, and
these factors continue to widen this gap during the pandemic.
In examining the reasons why digital solutions are not working
as well as we hope, Winkle et al7 present factors that affect adoption
and execution of available healthcare technology, delivery platforms
and digital devices. While somewhat sobering and overwhelming to
review, they illustrate the various ways that technology can be used
to serve the populations that currently are not benefitting to the ful-
lest extent—with a great deal of restructuring how the current sys-
tem works. These admittedly are not quick fixes, especially while in
the midst of a pandemic; however, some are more readily initiated,
such as integration of community workers. Others are to be aimed
for in future and worked toward steadily rather than accept the cur-
rent status quo.
Currently, both the CARES and 529 Meeting Street clinics con-
tinue serving patients in limited capacities while examining options
for expanding care that adhere to CDC guidelines for safety. Our lo-
cal healthcare system has been responsive in addressing these noted
deficiencies and working with us to develop ways to ensure all
patients have more equitable access to available services. In addition
to the factors raised in this article, there are others such as insurance
coverage and transportation access that additionally contribute to
successful usage of telehealth.
The COVID-19 pandemic will change the way we deliver health
care, and we suspect that there will be a greater reliance on and inte-
gration of technology going forward. The complexity of social and
health issues that contribute to accessibility and adoption of health-
related technologies has to be more fully examined and addressed
before the benefits can be realized to the fullest extent in all popula-
tions. Otherwise, despite advancements, we will continue to increase
disparities in healthcare access and outcomes, often to the detriment
of those who are most vulnerable in times of crises.
AUTHOR CONTRIBUTIONS
All authors have made substantial contributions to the conception
or design of the work, drafting the work and revising it critically for
important intellectual content; have given final approval of the ver-
sion to be published; and are in agreement to be accountable for all
aspects of the work in ensuring that questions related to the accu-
racy or integrity of any part of the work are appropriately investi-
gated and resolved.
CONFLICT OF INTEREST STATEMENT
The authors have no competing interests to declare.
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